Background A recent report completed by the Australian National Hospital and Health Care Reform Commission made recommendations for reform of the primary health care system, including the need to ensure health care organisation is underpinned by the inclusion of the views of all Australians and the sustainability of rural service delivery through innovative workforce models. Previous research has concluded that it is unrealistic to introduce new approaches to health care delivery, particularly in relation to workforce reform, without first understanding how patients perceive the current roles of primary health care professionals. This study explores the perceptions patients have of their rural primary health care professionals and explores the impact of this in relation to innovative approaches to achieve sustainable rural primary health care delivery.

Aims and objectives The key aim of this study is to explore individual patient perceptions of existing primary health care professionals (general practitioners, nurses, allied health professionals and ambulance paramedics) in four discrete rural and remote service locations (RRMAs 5-7). The services represent the four main variants of primary health care delivery in north Queensland and include both GP and non-GP led models of care. The objectives are the identification and investigation of: (i) individual patient perceptions of existing health care professionals; and the perceptions of the PHC professionals themselves, in four rural communities; (ii) broad differences and similarities between rural patients’ perceptions of PHC professionals and the key factors that contribute to these differences (with particular focus on the role of patient experience and the context of service delivery); (iii) patient perceptions of the broad archetypal views of the health care professions; and (iv) how these perceptions may impact on the development and introduction of innovative approaches to primary health care delivery. Methods The study design has two stages: (i) development of detailed case study profiles for each of four health care services and rural communities; including in-depth interviews with a total of 16 primary health care professionals; and (ii) in-depth semi-structured interviews with 43 patients. Stage two is informed by findings from a review of the national and international literature relating to patient perceptions. Interviews explore perceptions of health care professionals from patients’ ‘lived experiences’ of these roles. In addition, patient perceptions of primary health care profession archetypes (or stereotypes) are also investigated. An adapted organisational change theory approach is used as the theoretical basis for data analysis. Data are managed using QSR NVivo7 software and emergent themes relating to patient perceptions of their primary health care professionals are compared and contrasted across all interviews. Findings are then explored in the context of the case study profiles.

Results Patient perceptions of health care professionals are identified that are common to all interviews, regardless of service type. These are that the health care professional (i) ‘knows’ the patient well; (ii) ‘has and imparts confidence’; and (iii) ‘refers’ when necessary. In contrast to this, patients of non-GP led models of care are more likely to equate their primary health care professional as doing ‘everything a doctor does’. Patients of solo GP services are more likely to perceive the GP as a leader and the ‘essential care professional’ and nurses as ‘assistants’. However, patients of the Multipurpose Health Service place less emphasis on the skills and roles of the GPs. They also appear to perceive nursing roles in terms of diversity and flexibility, rather than in relation to key skills. Stereotypical beliefs of health professions are GPs as ‘leaders’, nurses as ‘Florence Nightingales’ and ambulance paramedics as the ‘bearers’. However, it appears that patients only apply them in relation to the GP-led service models.

Discussion There are several strengths and limitations to the data. Strengths include the development of detailed and data rich case studies with strategies to ensure the trustworthiness of the findings within the present policy environment. Limitations relate to small numbers of interviews and the uniqueness of the Queensland health care delivery context. These factors may limit the transferability of the findings to other rural settings. Patient perceptions are influenced by three factors: (i) the age and gender of the participant; (ii) the longevity of the professional in the community; and (iii) the way in which care is organised and delivered. The roles and skills of allied health professionals and ambulance paramedics are not well understood by rural patients; regardless of their exposure to these groups. Findings suggest that patients appear to value primary health care professionals who are long-term residents in the community, regardless of discipline. In addition, patients do not appear to apply beliefs of a medical hierarchy to their perceptions of the skills and roles of their primary health professionals. Health systems and primary health care professionals themselves may thus act to maintain medical hierarchies which patients do not perceive.

Conclusions While GPs continue to provide the necessary clinical support, they are not necessarily perceived as the essential resident health care professional. This has important implications for the development, introduction and sustainability of innovative workforce approaches and team-based health care delivery in rural settings. Trials of innovative workforce roles may have increased success if they are matched to the characteristics of local communities. Further research is needed to identify and support existing team-based approaches that may already exist in many rural and remote primary health care services.